Comprehensive Health Questionnaire Patient Information Mr. Ms. Miss Mrs. Dr. First Name: Middle Initial: Last Name: Age: Date of Birth: Height: Weight: Referred by: DDS MD DO DC Other Address and/or Phone Number of Healthcare Provider: Patient Address: City: State: Zip: Home Phone: Alternate Contact Number: Email: Type of Employment: Place of Employment: Responsible Party (if different than patient): Address: City: State: Zip: Family Physician: Phone Number: Family Dentist: Phone Number: What is your chief concern and reason for this visit: What are the results you are seeking from treatment: Do you currently experience any of the following symptoms? Please number your chief complaints 1-4 Recent Chronic Recent Chronic Headache (inside your head) Headache (outside your head) Jaw Pain Chewing Pain Face Pain Eye Pain Throat Pain Neck Pain Shoulder Pain Back Pain Dyskinesia Difficulty Opening Mouth Difficulty Closing Mouth Noises in Jaw Joints Ear Stuffiness Dizziness Ringing in Ears (Tinnitis) Vision Problems Muscle Spasm Sinus Congestion Kicking or jerking leg repeatedly Swelling in ankles or feet Numbness (Localized) Nerve Pain Morning Hoarseness Dry Mouth Upon Waking Fatigue Difficulty Falling Asleep Tossing and Turning Frequently Repeated Awakening Feeling Un- refreshed in the Morning Morning Headaches Nighttime Urination Night Sweats Vivid Dreams Sore Jaw Upon Waking Significant Daytime Drowsiness Affect Sleep of Others Short of Breath when Waking Told I stop breathing During Sleep Night- Time Choking Spells Unable to Tolerate C- Pap Tooth Grinding Teeth Crowding Frequent Heavy Snoring Acid Indigestion Dental Changes Teeth Spacing Teeth Sensitivity Changes with your Bite Any Other Symptoms not listed above 1
Sleep Conditions - Please select the yes or no answers based on your average sleep experience and/or what a sleep partner has told you Sleep Position? Side Back Stomach Varies Sleep Location? Bed Couch Chair Other Bed Partner? Yes No Average hours of sleep per night? Is it easy to fall asleep? Yes No Average hours of sleep per day? Do you wake often during the night? Yes No Cough, gasps or snorts on waking? Yes No Do you feel rested upon waking? Yes No Observed pauses in breath? Yes No Stopped breathing during sleep? Yes No Have you ever had a Sleep Study? HST PSG No Result: Previous Positive Airway Pressure Devices Used? CPAP BiPAP ASV APAP Do you currently use a PAP Device? Yes No Type: Previous Oral Appliance? Yes No Type: Allergic Reactions Please check any and all medications or substance that have caused an allergic reaction Anesthetics Antibiotics Aspirin Barbiturates Codeine Iodine Latex Metals Plastics Penicillin Sedatives Sulfa Food Allergies/Sensitivities Other: Current Medications Please list all medications and supplements (over- the- counter and prescription) you are taking and the reason you take them. Medication Dosage Reason for Taking See attached list Previous Treatment, Medications and Other Therapies Attempted For The Condition We Are Evaluating Treatment/Med/Therapy Doctor/Provider Approx. Date of Tx Helpful (y/n) See attached list Health And Medical History Are you currently pregnant? Yes No Do you drink 4 or more cups of coffee per day? Yes No Do you smoke tobacco? Yes No Do you consume alcohol or take sedatives? Yes No Do you have trouble breathing through your nose? Yes No Have you had prior orthodontic treatments? Yes No Have you sustained injury to: Head Neck Face Teeth Other: Surgical History - Have you had any of the following: General Anesthesia Yes No Orthognathic Surgery Yes No Adenoids Removed Yes No Oral Surgery Yes No Tonsils Removed Yes No Removal of Third Molar Yes No Jaw Joint Surgery Yes No (Wisdom Teeth) Other types of surgery: 2
Additional Health And Medical History Do you have or have you experienced any of the following Anemia Anxiety Asthma Bleeding Easily Birth Defects Bruising Easily Cancer of Chemo Chronic Fatigue Cold Hands and Feet COPD Yes No Fam Hx Depression Yes No Fam Hx Diabetes Yes No Fam Hx Difficulty Concentrating Difficulty Breathing at Night Dizziness Emphysema Epilepsy Excessive Thirst Fainting Fibromyalgia Fluid Retention Frequent Colds/Flu Frequent Cough Frequent Ear Infections Frequent Sore Throat Awakening from Sleep x Gastroesophogeal Reflux Glaucoma Hay Fever Hearing Impairment Heart Attack Heart Disease Yes No Fam Hx Heart Murmur Heart Pacemaker Heart Palpitations Heart Valve Replacement Hemophilia Hepatitis High Blood Pressure Yes No Fam Hx History of Substance Abuse Huntington s Disease Hypoglycemia Insomnia Intestinal Disorder Irregular Heartbeat Kidney Disease Leukemia Liver Disease Low Blood Pressure Meniere s Disease Memory Loss Migraines Mitral Valve Prolaps Multiple Sclerosis Muscle Aches Muscle Fatigue Muscle Spasms Muscular Dystrophy Neuralgia Nervous system Disorder Osteoarthritis Osteoporosis Ovarian Cyst Parkinson s Disease Poor Circulation Psychiatric Care Radiation Recent Weight Gain Recent Weight Loss Rheumatic Fever Rheumatoid Arthritis Scarlet Fever Shortness of Breath Skin Disorder Sinus Problems Slow Healing Sores Speech Difficulties Stroke Swollen or Painful Joints Thyroid Disease Tired Muscles Tuberculosis Urinary Tract Disorder 3
Additional Symptoms Head Pain Location Recent Chronic Severity Duration Frequency L = Left R = Right B = Bilateral (over 6mo.) Mild Mod Severe Hrs Days Wks Occ. Freq Constant Temple Area L R B Back of Head L R B Forehead L R B Top of Head L R B All of Head L R B Jaw Pain 4 Jaw Joint Sound Jaw pain with opening L R Jaw sounds with opening L R Jaw pain when chewing L R Jaw sounds when chewing L R Jaw pain at rest L R Jaw Locking Jaw Joint Symptoms Jaw locks closed Yes No Teeth clenching Yes No Day Night Jaw locks open Yes No Teeth grinding Yes No Day Night Eye Related Conditions Blurred vision Yes No Pain or pressure behind the eyes Yes No Double vision Yes No Extreme sensitivity to light Yes No Eye pain Yes No Wear of glasses or contacts Yes No Ear Related Conditions Buzzing in ears L R Pain behind the ear L R Ear Congestion L R Pain in front of ear L R Ear pain L R Recurrent ear infections L R Hearing Loss L R Ringing in the ear (tinnitus) L R Itchiness/stuffiness L R Throat Related Conditions Chronic sore throat Yes No Thyroid enlargement Yes No Difficulty Swallowing Yes No Tightness in throat Yes No Swollen glands Yes No Feeling of foreign object in throat Yes No Neck related Conditions Limited movement Yes No Numbness in hands/fingers Yes No Neck pain Yes No Swelling in neck Yes No Shoulder Conditions Pain in Shoulder Yes No Tingling in fingers/hands Yes No Stiffness in Shoulder Yes No Back Conditions Low Back Pain Yes No Scoliosis Yes No Middle Back Pain Yes No Sciatica Yes No Upper Back Pain Yes No Mouth/Nose Conditions Chronis Sinusitis Yes No Broken Teeth Yes No Dry Mouth Yes No Biting Cheeks Yes No Frequent Snoring Yes No Burning Tongue Yes No
History of Symptoms On what date, or approximate date, did the condition you are seeking treatment for occur? Are any of the conditions listed or was your chief complaint caused by a motor vehicle accident? Yes No If yes, what conditions: Date of accident: Does any family member have a sleep breathing disorder? Yes No If yes, explain: Adult - Complete this section 1. DAYTIME SLEEPINESS EVLAUATION - EPWORTH SLEEPINESS SCALE For the following situations, answer with one of the following numbers: 0 - would never doze 1 - slight chance of dozing 2 - moderate chance of dozing 3 - high chance of dozing Situation Score Situation Score Sitting and reading Sitting and talking to someone Watching Television Sitting quietly after a lunch (no alcohol) Sitting, inactive public place In a car, while stopped for a few minutes in traffic As a passenger in a car for an Lying down to rest in the afternoon when hour without a break circumstances permit 2. NIGHTTIME SLEEPINESS EVALUATION Developed by David White, M.D., Harvard Medical School, Boston, MA TOTAL SCORE 1. Snoring Score a) Do you snore on most nights (>3 nights per week)? b) Is your snoring loud? Can it be heard through a door or wall? 2. Has it ever been reported to you that you stop breathing or gasp during sleep? Never (0) Occasionally (3) Frequently (5) 3. What is your collar size? Male: Less than 17 inches (0) More than 17 inches (5) Female: Less than 16 inches (0) More than 16 inches (5) 4. Do you occasionally fall asleep during the day when: a) You are busy or active b) You are driving or stopped at a light? 5. Have you had or are you being treated for high blood pressure? TOTAL I authorize the release of all examination findings and diagnosis, report and treatment plans, etc., to any referring or treating health care provider. I additionally authorize the release of any medical information to insurance companies, third party billing companies, or for legal documentation to process claims. I understand that I am responsible for all charges incurred for my treatment regardless of insurance coverage. 5
3. Child - Complete this section BEARS SLEEP SCREENING ALGORITHM The BEARS instrument is divided into five major sleep domains, providing a comprehensive screen for the major sleep disorders affecting children in the 2- to 18- year old range. Each sleep domain has a set of age- appropriate trigger questions for use in the clinical interview. B = bedtime problems E = excessive daytime sleepiness A = awakenings during the night R = regularity and duration of sleep S = snoring A parent answers questions in black, the subject child answers questions written in blue: Symptom Age Toddler/Preschool (2-5 years) 1. Bedtime Problems Does your child have any problems going to bed? Y N 2. Excessive Daytime Sleepiness Does your child seem overtired or sleepy a lot during the day? Y N 3. Awakenings during the night Does your child wake up a lot at night? (P) Y N Age School Age (6-12 years) Does your child have any problems at bedtime? (P) Y N Do you have any problems going to bed? (C) Does your child have difficulty waking in the morning, seem sleepy during the day or take naps? (P) Y N Do you feel tired a lot? (C) Y N Does your child seem to wake up a lot at night? Y N Any sleepwalking or nightmares? (P) Y N Do you wake up a lot at night? Y N Age Adolescent (13-18 years) Do you have any problems falling asleep at bedtime? (C) Y N Do you feel sleepy a lot during the day? Y N In School? Y N While Driving? (C) Y N Do you wake up a lot at night? Y N Have trouble getting back to sleep? (C) Y N 4. Regularity and duration of sleep Does your child have a regular bedtime and wake time? Y N What are they? Have trouble getting back to sleep? (C) Y N What time does your child go to bed and get up on school days? Weekends? Do you think he/she is getting enough sleep? (P) Y N What time do you usually go to bed on school nights? Weekends? How much sleep do you usually get? (C) 5. Snoring Does your child snore a lot or have difficult breathing at night? Y N (P) Parent- directed question (C) Child- directed question Does your child have loud or nightly snoring or any breathing difficulties at night? (P) Y N Does your teenager snore loudly or nightly? (P) Y N Source: A Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems by Jodi A. Mindell and Judith A. Owens; Lippincott Williams & Wilkins 6